A Gentle Yoga Sequence for Back Pain

"Happy families are all alike," Tolstoy wrote. "Every unhappy family is unhappy in its own way." The same thing— or something quite similar—might be said of our backs.

As long as they're "back" there doing their job, holding us up and keeping us mobile, we usually don't give them too much thought; we can't even see them. We take them for granted. They're just backs—our posterior sides, the very definition of strength and silence.

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But as soon as our backs go out, we all have stories to tell. Suddenly our lives—once so pain free—are limited and defined by our own personal brew of sports mishaps and mistimed sneezes, of sleepless nights and missed workdays, of social lives curtailed and family activities indefinitely altered. We each become unhappy in our own excruciating way the moment that lower back pain comes creeping into the picture. And eventually, it almost always does. (To find out why, see Garden-Variety Back Pain.)

For Terri Stoecker, 54, the moment came one day last year while she quietly worked in the garden at her summer home in Chestertown, New York. She was planting a row of hemlock trees when her lower back suddenly seized up. "I could barely move; my back was just completely locked," she remembers. A neighbor helped her into the house, where she rested up enough to return to Florida and begin an odyssey of doctor's visits, MRI scans, prescription refills, and physical therapy sessions.

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As it so often does, back pain snuck up on Stoecker and took her by surprise. She couldn't quite believe what was happening to her. "I was a marathon runner and a competitive tennis player—I was an active person," says the former flight attendant, who worked a total of 28 years for TWA and American Airlines before recently retiring. "I thought I was strong, but it turns out that I wasn't strong in the right places." Plus, she says, "I was absolutely devastated. I couldn't imagine what I would do if I couldn't find a way to get my life back."

Luckily, she did. By happenstance—or what Stoecker now sees as synchronicity—she found something that she believes truly healed her back: a Viniyoga class taught by a physical therapist named Emily Large, who bases her instruction on the work of Gary Kraftsow, author of the seminal Viniyoga book Yoga for Wellness. "After the first class, I knew this was for me," Stoecker remembers. "Relief came quickly. The combination of physical movement, mental awareness, concentration, and breathing just worked."

Yoga Works

In 2005, a groundbreaking study found that patients with chronic lower back pain who participated in a 12-week series of yoga classes had less pain and more improved function than those in the study's other groups. One group took conventional exercise classes (a combination of strength training, cardio, and stretching based on physical therapy techniques). The other group cared for themselves at home using a provided back-pain handbook.

What's more, the benefits of yoga extended well beyond the scope of the classes. When researchers followed up with the participants after 26 weeks, they found continued improvement in function and pain relief. The patients also used less medication.

Karen Sherman designed the study, which was funded by the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health. She is an epidemiologist and a researcher for Group Health, an integrated health care system in Seattle with upward of 500,000 patients. Sherman's idea was to test yoga as a treatment not for experienced yoga practitioners with specific injuries, but for the kinds of people that doctors were seeing in their offices every day. "To make these results the most relevant, we were looking for what most people have—general, nonspecific lower back pain. We weren't looking for people who were into yoga," she says. "We were looking for people who were into making their back pain better."

She found 101 patients willing to participate in her study, and most of those who were in the yoga course experienced relief. But when Sherman discusses her work, she's circumspect. "In my view, one study never proves anything," she says. "But this does suggest that for people who have garden-variety lower back pain, it's totally worthwhile to give yoga a try."

Rich Panico is more enthusiastic about Sherman's results. As founder of the Mind Body Institute at Georgia's Athens Regional Medical Center and designer of the Back Care Yoga program there, he's a physician in the business of communicating the power of yoga to other physicians. "This is big news," he says. "It's one of the first meaningful yoga studies. We live in the era of evidence-based medicine, [and] everybody's looking for proof. Doctors can see that this study has the statistical power to draw meaningful conclusions: Yoga helps people with back pain, and it's an enduring phenomenon."

There have been other studies about yoga helping to relieve back pain that have been published in smaller medical journals, such as the International Journal of Yoga Therapy. But this study really gets doctors' attention, Panico says. "It was methodologically rigorous, well constructed, and published in a prestigious peer-reviewed journal," he explains. "It's just good science. You can't ignore it."

Function over Form

If you're reading this magazine, Panico's efforts to sway the skeptical might seem, well, familiar. Chances are you already know all about yoga's potential to heal. But maybe you, too, have experienced frustrating resistance from your cranky aching co-worker or incapacitated aunt—people in your life who you know could benefit from yoga but who still think of it as something too fringe or too difficult. This evidence is for them, too: Yoga does work.

Which is not to say that all yoga works for back pain. Before Sherman set up the study, she had to identify a form of yoga that would be accessible to a wide range of people. "It had to be something people could really do; I didn't want anything overly difficult or esoteric," she explains. "I also didn't want any adverse events. I wanted something safe."

Sherman began interviewing yoga teachers in the Seattle area, looking for the best fit. She found it in Robin Rothenberg, director of The Yoga Barn studios. Rothenberg was knowledgeable, experienced, and intelligent. Better yet, she was teaching a form of yoga that was perfect for the study: Viniyoga.

Yoga for Every Body

A gentle style, Viniyoga emphasizes the breath, simple and repetitive movements, careful sequencing, and the use of yoga as a therapeutic tool. Viniyoga has been popularized in the United States by Gary Kraftsow, whose main teacher was T.K.V. Desikachar, son of the great Indian yogi Krishnamacharya. Kraftsow, in turn, is Rothenberg's teacher.

"Viniyoga is simple and accessible to everyone," says Rothenberg, a certified Viniyoga therapist who's also been a certified Iyengar teacher. "If you can move, if you can breathe, if you can get down on the floor or sit in a chair, you can do Viniyoga. Downward Dog is a complex pose; Triangle is a complex pose. But people can understand bringing their knees into their chests."

Kraftsow worked with Rothenberg to develop asana sequences, which they based on Kraftsow's yoga therapy and Rothenberg's Iyengar background.

"Viniyoga is easy for people who aren't so yoga oriented and tuned in to their bodies," Rothenberg says. "During the course of the study, we had people who came to our classes and said they'd never considered doing yoga, but they were in so much pain. They were able to do it, and they got results. They felt better; they slept better. They were able to do things again, like hiking or gardening or playing tennis. They were getting their lives back."

Exactly why Viniyoga works is a matter of some debate. The study itself did not draw any clear conclusions. Theorizing that the results were due to a combination of mental focus and physical movement, the study simply noted that more research was needed to identify "mechanisms of action." (Another Sherman-led, NCCAM-funded, Viniyoga-focused study on this subject is currently under way.)

"The protocol Robin and I developed is about adapting the postures to reduce symptoms," Kraftsow says. "It's aimed at strengthening what's weak, balancing what's asymmetrical, releasing chronic contraction, and building proprioceptive awareness. It is not about mastering the forms of the postures."

Still, Kraftsow says that caution is needed before one embraces the results of this study wholesale. "Viniyoga is a sophisticated science of sequencing," says Kraftsow. "The right sequence can heal you; the wrong sequence can make things worse. The medical community should be aware that just because this study is evidence based doesn't mean that all yoga will be good for back pain. Not even all Viniyoga will be good for back pain. Yoga that is adapted intelligently for the purpose of working with back pain, as our sequence was, will be good for back pain. Other yoga can send you to the hospital."

In the world of yoga—even therapeutic yoga, unfortunately—it's caveat emptor. Looking for a teacher whose name is followed by "C.Y.T." (certified yoga therapist) is a good place to start, Kraftsow suggests. If that's not possible in your area, look for a gentle form of yoga in which jumping or intense forward bending are not part of the class. Talk to your teachers beforehand to ascertain their level of experience, and make sure that individual needs can be accommodated. And, if possible, take a private lesson before you sign up for a class.

Back Off the Mat

Emily Large, Terri Stoecker's yoga teacher, has her own theory about how and why yoga works so well. Large, who is a physical therapist and certified Viniyoga therapist practicing in West Palm Beach, Florida, as well as Atlanta, transformed her physical therapy practice when she started adding yoga into the mix. "Yoga provides people with a tool for self-discovery," she says. "The postures, combined with the breathwork and meditative qualities of the movement, lead to self-awareness in the body. The repetitive movements that are unique in Viniyoga warm the body and increase circulation, which is important in healing. They also break poor movement patterns and introduce healthy ones."

"Overall," concludes Large, "it's a more holistic approach to rehabilitation. It lets people heal themselves. When you learn healthy habits in yoga, it carries over into your daily life."

Stoecker believes that the techniques she has learned in Large's class have allowed her to return to her active lifestyle. "You can let your back control you and change your life into something sedentary and painful, or you can find something that can keep you healthy and get you back to 95 percent normal. I was told I would never run or garden again. Now I can do those things. I have to be careful, I have to take care of myself, but I live my life. Yoga has done that for me."

This assessment makes Kraftsow a very happy man—it is the perfect realization of his intention. "It's important to remember that the study of yoga is not about anything external to you," he says. "It's about studying yourself and learning tools to reduce the undesirable things in your life, like back pain, and increase the positive things, like happiness. It's about refining yourself at all levels."

"We're not talking about fancy yoga or power yoga here," he adds. "You don't need an hour-long class or a special outfit or a fancy mat to do this. This practice is available to everybody. You can learn it easily and use it to feel better and really begin to manage your condition." Try it for yourself.